[Carrier] HMO PLAN
SMALL GROUP HEALTH MAINTENANCE ORGANIZATION (HMO)CONTRACT
CONTRACTHOLDER: [ABC Company]
GROUP CONTRACT NUMBER GOVERNING JURISDICTION
[G-12345] NEW JERSEY
EFFECTIVE DATE OF CONTRACT: [September 23, 2010 ]
CONTRACT ANNIVERSARIES: [September 23rd of each year, beginning in 2011 ]
PREMIUM DUE DATES: [Effective Date, and the 23rd day of the month beginning with October 2010.]
AFFILIATED COMPANIES: [DEF Company]
[Carrier], in consideration of the application for this Contract and the payment of premiums as stated herein, agrees to arrange [or provide] services and supplies in accordance with and subject to the terms of this Contract. This Contract is delivered in the jurisdiction specified above and is governed by the laws thereof.
The provisions set forth on the following pages constitute this Contract.
The Effective Date is specified above.
This Contract takes effect on the Effective Date, if it is duly attested below. It continues as long as the required premiums are paid, unless it ends as described in its General Provisions.
[Secretary President]
[ “DC” THIS SMALL GROUP HEALTH MAINTENANCE ORGANIZATION CONTRACT (HMO PLAN), ISSUED BY [CARRIER] IS ISSUED IN CONJUNCTION WITH THE SMALL GROUP HEALTH BENEFITS POLICY (INDEMNITY PLAN) ISSUED BY [CARRIER]. TOGETHER, THIS HMO PLAN AND THE INDEMNITY PLAN ISSUED BY [CARRIER] PROVIDE POINT OF SERVICE COVERAGE.]
[Include legal name, trade name, phone, fax and e-mail numbers by which consumers may contact the carrier, including at least one toll-free number for Members]
TABLE OF CONTENTS
Section Page
SCHEDULE OF PREMIUM RATES AND CLASSIFICATION
[“DC” OVERVIEW OF POINT OF SERVICE PLAN]
SCHEDULE OF SERVICES AND SUPPLIES
DEFINITIONS
ELIGIBILITY
[MEMBER] PROVISIONS
[COVERAGE PROVISION]
COVERED SERVICES AND SUPPLIES
NON-COVERED SERVICES AND SUPPLIES
COORDINATION OF BENEFITS AND SERVICES
GENERAL PROVISIONS
CONTINUATION RIGHTS
MEDICARE AS SECONDARY PAYOR
SCHEDULE OF PREMIUM RATES AND CLASSIFICATION
[The monthly premium rates, in U.S. dollars, for the coverage provided under this Contract are:
Covered Employee Only...... $ ]
[Covered Employee and Spouse...... $
Covered Employee and Child(ren)...... $
Covered Employee and Family...... $
(including Covered Employee, spouse and one or more eligible dependents)]
We have the right to prospectively change any Premium rate(s) set forth above at the times and in the manner established by the provision of this Contract entitled " General Provisions."
[“DC” Note: The premium rates set forth above are for coverage under this HMO Plan only. Refer to the Indemnity Plan issued in conjunction with this HMO Plan, for information on the premium rates applicable to the Indemnity Plan coverage.]
______
This Contract’s classifications, and the coverages and amounts which apply to each class are shown below:
CLASS(ES)
[All eligible employees]
[“DC” OVERVIEW OF POINT OF SERVICE PLAN (Copayment, Deductibles, and Coinsurance)
[NETWORK] (Provided under this HMO Plan)Copayment
For Preventive Care NONE
For all other Services and Supplies $[15], unless otherwise stated
Emergency Room Copayment $50, credited toward Inpatient admission if
admitted within 24 hours
Coinsurance 0% [except as stated on the Schedule of Services
and Supplies for Prescription Drugs]
[NON-NETWORK] (Provided under the Indemnity Plan)
Cash Deductible (calendar
year, all cause) [$2,500] per person except as stated for Preventive Care
[$5,000 per family][Note: Must be
individually satisfied by 2 separate [Members]]
[ $7,500]
Emergency Room Copayment (waived
if admitted within 24 hours) [$50]
Coinsurance
For Preventive Care NONE
For all other Covered Charges [30%, 20%]
Maximum Out of Pocket $7,500
MAXIMUM LIFETIME BENEFITS Unlimited,
SCHEDULE OF SERVICES AND SUPPLIES [Using Copayment]
THE SERVICES OR SUPPLIES COVERED UNDER THIS CONTRACT ARE SUBJECT TO ALL COPAYMENTS [AND COINSURANCE] AND ARE DETERMINED PER CALENDAR YEAR PER [MEMBER], UNLESS OTHERWISE STATED. MAXIMUMS ONLY APPLY TO THE SPECIFIC SERVICES PROVIDED.
[SERVICES COPAYMENTS[/COINSURANCE]:
HOSPITAL SERVICES:
INPATIENT [$75, $100, $150, $200, $300, $400, $500] Copayment/day for a maximum of 5 days/admission. Maximum Copayment [$750, $1000, $1,500, $2,500, $3,000, $4,000, $5,000]/Calendar Year. Unlimited days.
OUTPATIENT [$5, $10, $15, $20, $30, $40, $50] Copayment/visit
PRACTITIONER SERVICES RECEIVED AT A HOSPITAL:
INPATIENT VISIT $0 Copayment
OUTPATIENT VISIT [$5, $10, $15, $20, $30, $40, $50] Copayment/visit; no Copayment if any other Copayment applies.
EMERGENCY ROOM [at the option of the carrier,$50, $75 or $100] Copayment/visit/Member (credited toward Inpatient Admission if Admission occurs within 24 hours)
Note: The Emergency Room Copayment is payable in addition to the applicable Copayment and Coinsurance, if any.
SURGERY:.
INPATIENT $0 Copayment
OUTPATIENT [$5, $10, $15, $20, $30, $40, $50] Copayment/visit
HOME HEALTH CARE Unlimited days, if Pre-Approved; $0 Copayment.
HOSPICE SERVICES Unlimited days, if Pre-Approved; $0 Copayment.
MATERNITY (PRE-NATAL CARE) [at the option of the carrier, $25 or same amount as primary care physician copayment] Copayment for initial visit only; $0 Copayment thereafter.
THERAPEUTIC MANIPULATION [$5, $10, $15, $20, $30, $40, $50] Copayment/visit; maximum 30 visits/Calendar Year
PRE-ADMISSION TESTING [$5, $10, $15, $20, $30, $40, $50] Copayment/visit.
PRESCRIPTION DRUG 50% Coinsurance [May be substituted by Carrier with $15 Copayment.]
PRIMARY CARE PHYSICIAN
For services other than Preventive Care [$5, $10, $15, $20, $30, $40, $50] Copayment/visit.
[OR CARE MANAGER] SERVICES
(OUTSIDE HOSPITAL)
PRIMARY CARE SERVICES
other than Preventive Care [$5, $10, $15, $20, $30, $40, $50] Copayment/visit.
PREVENTIVE CARE $0 copayment
REHABILITATION SERVICES Subject to the Inpatient Hospital Services Copayment above. The Copayment does not apply if Admission is immediately preceded by a Hospital Inpatient Stay.
SECOND SURGICAL OPINION [$5, $10, $15, $20, $30, $40, $50] Copayment/visit.
SPECIALIST SERVICES [$5, $10, $15, $20, $30, $40, $50] Copayment/visit.
SKILLED NURSING FACILITY/EXTENDED CARE CENTER Unlimited days, if Pre-Approved; $0
Copayment.
THERAPY SERVICES [$5, $10, $15, $20, $30, $40, $50] Copayment/visit.
Speech and Cognitive Therapy (Combined),
maximum30 visits per Calendar Year
See below for the separate speech therapy benefits available under the
Diagnosis and Treatment of Autism and Other Developmental
Disabilities Provision
Physical and Occupational Therapy (Combined)
maximum 30 visits per Calendar Year
See below for the separate benefits available under the
Diagnosis and Treatment of Autism and Other Developmental
Disabilities Provision
Charges for speech therapy provided under
the Diagnosis and Treatment of Autism and Other Developmental
Disabilities Provision 30 visits per Calendar Year
Charges for physical and occupational provided
under the Diagnosis and Treatment of Autism and Other
Developmental Disabilities Provision (combined benefits) 30 visits per Calendar Year
DIAGNOSTIC SERVICES .
INPATIENT $0 Copayment
(OUTPATIENT) [$5, $10, $15, $20, $30, $40, $50] Copayment/visit
HEARING AIDS
for Members age 15 or younger [$5, $10, $15, $20, $30, $40, $50] Copayment with coverage limited to $1,000 per hearing impaired ear per 24-month period
SCHEDULE OF SERVICES AND SUPPLIES [Example Using Deductible, Coinsurance]
The services or supplies covered under this Contract are subject to the Copayments Deductible and Coinsurance set forth below and are determined per Calendar Year per [Member], unless otherwise stated. Maximums only apply to the specific services provided.
COPAYMENT
For Preventive Care NONE
For all other Primary Care Physician Visits [$5, $10, $15, $20, $30, $40, $50] per visit
Maternity (pre-natal care) [at the option of the carrier, $25 or same amount as primary care physician copayment] Copayment/initial visit.
For all other services and supplies Copayment Not Applicable; Refer to the Deductible and Coinsurance sections
DEDUCTIBLE PER CALENDAR YEAR
·For Primary Care Physician Visits
including Preventive Care and immunizations
and lead screening for children NONE
·Maternity (pre-natal care) NONE.
·for all other Covered Services and Supplies
·Per Covered Person [$250 to $2,500]
· [Per Covered Family [Dollar amount which is two times the individual Deductible.] Note: Must be individually satisfied by 2 separate Members
COINSURANCE
For Preventive Care 0%
Prescription Drugs 50%
For all services and supplies to which a
Copayment does not apply [10% - 50%, in 5% increments]
For all services and supplies to which a
Copayment applies None
EMERGENCY ROOM COPAYMENT [at the option of the carrier, $50, $75, $100] Copayment/visit/Member (credited toward Inpatient admission if admission occurs within 24 hours as the result of the emergency).
Note: The Emergency Room Copayment is payable in addition to the applicable Copayment, Deductible and Coinsurance.
MAXIMUM OUT OF POCKET
Maximum Out of Pocket means the annual maximum dollar amount that a Member Person must pay as Copayment, Deductible and Coinsurance for all covered services and supplies in a Calendar Year. All amounts [for services and supplies other than Prescription Drugs] paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for covered services and supplies [other than Prescription Drugs] for the remainder of the Calendar Year.
The Maximum Out of Pocket for this Contract is as follows:
·Per Member per Calendar Year [An amount not to exceed $7,500]
· [Per Member per Calendar Year [Dollar amount equal to two times
the per Member Maximum.]
[Note: Must be individually satisfied by 2 separate Members]]
Note: The Maximum Out of Pocket cannot be met with Non-Covered Charges or with charges for Prescription Drugs.
LIMITATIONS ON SERVICES AND SUPPLIES
Home Health Care Unlimited days, subject to Pre-Approval.
Hospice Services Unlimited days, subject to Pre-Approval.
Speech and Cognitive Therapy (Combined) 30 visits per Calendar Year
See below for the separate speech therapy benefits available under the
Diagnosis and Treatment of Autism and Other Developmental
Disabilities Provision
Physical and Occupational Therapy (Combined) 30 visits per Calendar Year
See below for the separate benefits available under the
Diagnosis and Treatment of Autism and Other Developmental
Disabilities Provision
Charges for speech therapy provided under
the Diagnosis and Treatment of Autism and Other Developmental
Disabilities Provision 30 visits per Calendar Year
Charges for physical and occupational provided
under the Diagnosis and Treatment of Autism and Other
Developmental Disabilities Provision (combined benefits) 30 visits per Calendar Year
Therapeutic Manipulation 30 visits per Calendar Year
Skilled Nursing Facility/
Extended Care Center Unlimited days, subject to Pre-Approval
Hearing Aids
for Members age 15 or younger [$5, $10, $15, $20, $30, $40, $50] Copayment with coverage limited to $1,000 per hearing impaired ear per 24-month period
NOTE: NO SERVICES OR SUPPLIES WILL BE PROVIDED IF A [MEMBER] FAILS TO OBTAIN A REFERRAL FOR CARE THROUGH HIS OR HER PRIMARY CARE PHYSICIAN [OR HEALTH CENTER] [OR THE CARE MANAGER]. READ THE [MEMBER] PROVISIONS CAREFULLY BEFORE OBTAINING MEDICAL CARE, SERVICES OR SUPPLIES.
REFER TO THE SECTION OF THIS CONTRACT CALLED "NON-COVERED SERVICES AND SUPPLIES" FOR A LIST OF THE SERVICES AND SUPPLIES FOR WHICH A [MEMBER] IS NOT ELIGIBLE FOR COVERAGE UNDER THIS CONTRACT.
[“DC” THIS HMO PLAN AND THE ASSOCIATED INDEMNITY PLAN MAY BOTH PROVIDE BENEFITS, SERVICES OR SUPPLIES FOR THE SAME SERVICE OR SUPPLY. TO THE EXTENT THAT BENEFITS ARE PROVIDED UNDER THE INDEMNITY PLAN, THE SERVICE OR SUPPLY WILL NOT BE COVERED BY THIS HMO PLAN. SIMILARLY, TO THE EXTENT THAT SERVICES OR SUPPLIES ARE PROVIDED UNDER THIS HMO PLAN, BENEFITS WILL NOT BE PROVIDED UNDER THE INDEMNITY PLAN.
FOR ANY SPECIFIC [NETWORK] SERVICES AND SUPPLIES PROVIDED UNDER THIS CONTRACT WHICH ARE SUBJECT TO LIMITATION, ANY SUCH SERVICES OR SUPPLIES THE [MEMBER] RECEIVES UNDER THIS HMO PLAN WILL REDUCE THE CORRESPONDING BENEFIT PROVIDED UNDER THE INDEMNITY PLAN FOR THAT SERVICE OR SUPPLY. SIMILARLY, FOR ANY SPECIFIC BENEFITS PROVIDED UNDER THE INDEMNITY PLAN WHICH ARE SUBJECT TO LIMITATION, ANY SUCH BENEFITS THE [MEMBER] RECEIVES AS INDEMNITY PLAN COVERED CHARGES WILL REDUCE THE CORRESPONDING HMO PLAN SERVICES AND SUPPLIES AVAILABLE FOR THAT SERVICE OR SUPPLY. THE SERVICES AND SUPPLIES SECTION OF THIS HMO PLAN AND THE COVERED CHARGES SECTION OF THE INDEMNITY PLAN CLEARLY IDENTIFY WHICH SERVICES AND SUPPLIES AND COVERED CHARGES ARE AFFECTED BY THIS REDUCTION RULE.]
DEFINITIONS
The words shown below have specific meanings when used in this Contract. Please read these definitions carefully. Throughout the Contract, these defined terms appear with their initial letters capitalized. They will help [Members] understand what services and supplies are provided.
ACCREDITED SCHOOL. A school accredited by a nationally recognized accrediting association, such as one of the following regional accrediting agencies: Middle States Association of Colleges and Schools, New England Association of Schools and Colleges, North Central Association of Colleges and Schools, Northwest Association of Schools and Colleges, Southern Association of Colleges and Schools, or Western Association of Schools and Colleges. An accredited school also includes a proprietary institution approved by an agency responsible for issuing certificates or licenses to graduates of such an institution.
[ACTIVELY AT WORK or ACTIVE WORK. Performing, doing, participating or similarly functioning in a manner usual for the task for full pay, at the Contractholder's place of business, or at any other place that the Contractholder's business requires the Employee to go.]
AFFILIATED COMPANY. A company defined in subsections (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986. All entities that meet the criteria set forth in the Internal Revenue Code shall be treated as one employer.
ALLOWED CHARGE. Means an amount that is not more than the [lesser of:
• the] allowance for the service or supply as determined by Us, based on a standard approved by the Board[; or
[• the negotiated fee schedule.]
The Board will decide a standard for what is an Allowed Charge under this Contract.
Please note: The Coordination of Benefits and Services provision includes a distinct definition of Allowed Charge.
AMBULANCE. A certified transportation vehicle for transporting Ill or Injured people that contains all life-saving equipment and staff as required by applicable state and local law.
AMBULATORY SURGICAL CENTER. A Facility mainly engaged in performing Outpatient Surgery. It must:
a) be staffed by Practitioners and Nurses, under the supervision of a Practitioner;
b) have operating and recovery rooms;
c) be staffed and equipped to give emergency care; and
d) have written back-up arrangements with a local Hospital for emergency care.
It must carry out its stated purpose under all relevant state and local laws and be either:
a) accredited for its stated purpose by either the Joint Commission or the Accreditation Association for ambulatory care; or